For about six weeks, from the beginning of June to the middle of July, I didn’t write a word for Economic Sociology, interrupting my steady two-posts-a-month rate. I wasn’t on vacation, but instead spending a lot of time with German doctors, trying to figure out why I suddenly couldn’t walk, sleep or eat without pain. I was sick, unable to walk a single step without holding onto something for support, and just miserable 24/7. It would have been a drag in any context, but trying to get help in a foreign language, in a country that is not exactly warmly disposed toward foreigners, made the whole situation very difficult.

One of the best parts of the experience, however, was a very small thing that made seeking medical help a lot less stressful: the segregation of the business part of a medical practice (the part that does billing and takes in payments) from the care-giving part. That means when you go to a doctor’s office, everyone from the office staff to the physician’s assistants to the doctors are focused on the same things that you are as a patient: dealing with what ails you. That’s what people in the business school world call “alignment of interests,” and it works very well in terms of minimizing the roadblocks between people in need of care and those who can provide it.

This separation of business from care in medicine also has a surprisingly comforting aspect emotionally, particularly if you’re used to a system in which the business part of medicine is inextricable from the care part. Though they are intertwined, they don’t work very well together. I think this is because, as Viviana Zelizer pointed out years ago in her article “Payments and Social Ties” (1996), the notions of “care” and “payment” are essentially antagonistic.

Probably every American has a story about the ways that the business part of a medical practice obstructed his or her ability to get care. I once knew a woman who, despite being well-insured, was harassed in her hospital bed by a billing department employee demanding to know how she–still groggy and in pain from an operation to save her life–was going to pay for her treatment; the hospital employee strongly implied that the woman would be “evicted” from her bed if she couldn’t prove that her bills would be paid. That apparently seemed like reasonable behavior to the hospital employee, “just doing her job” by looking out for the hospital’s business interests; the ethics of badgering an ill and vulnerable woman just out of surgery–in other words, the ethic of care–didn’t enter into the discussion.

These anecdotes do not argue against compensation for doctors–or any other caregivers, professional or otherwise. Rather, the point is that the motivations and incentives in relationships mediated by payment are often at odds with the motivations and incentives that we think are supposed to govern relationships defined by the term “care giving.” This is one reason many people have such a strong negative emotional response to the idea of paying stay-at-home spouses for their housework: the spouses are supposed to keep house, and possibly rear children, out of love and caring, not a desire to get paid; plus, there’s the fear that if stay-at-home spouses were paid, their emotional attachments to family members would deteriorate, replaced by a more impersonal employer-employee dynamic.

Back to Germany: Doctors certainly get paid for their services here, and seem to make a nice living. But when you walk into the reception area of their practices, you don’t see any apparatus for handling money: no credit card runners, no cash registers, nothing. All that is outsourced to firms located outside the doctors’ offices, often in different cities. Those outsource firms send a bill to your insurance firm, or–if you’re like me and have to pay every penny out of pocket–to you, the patient. Surprisingly, this doesn’t create the kind of snarled bureaucratic nightmare I would have expected: when I had questions about a bill from one of those outsource firms, I took the bill and the questions directly to my doctor, who called in his office assistant, and together they got on the phone with the billing firm and straightened things out for me on the spot.

This means that when you visit a doctor in Germany, the whole event is aligned around care from start to finish. That doesn’t make medicine a charitable undertaking, as some of the straw-man arguments in the US health care debate might lead you to think. Doctors here show no signs of having a forced choice between “doing well” and “doing good;” that distinction was also long held inviolate in the world of investing, and while the evidence has been around for over 15 years showing it to be a crock, it’s one of those snippets of economic ideology that seems impervious to reality.

Nor do patients face “rationing” of services in this system–apparently, the kinds of “socialized medicine” horror stories that Americans hear so often when we start talking about health care reform are drawn primarily from models like the NHS in Britian. Based on accounts from NHS patients, doctors and British politicians, that horror seems well-founded.

So this year [2008], two researchers at the London School of Hygiene and Tropical Medicine measured something called the “amenable mortality.” Basically, it’s a measure of deaths that could have been prevented with good health care. The researchers looked at health care in 19 industrialized nations. Again, France came in first. The United States was last.

Germany only made it to 12th on that list, but still–in nearly three years here, I have never heard a peep against the health care system, and certainly nothing remotely like the tragic litany of needless suffering (emotional and physical) and death that we hear in connection with the US system.

The French and German health care systems have another thing in common: they involve money (indeed, they are quite costly), but people living under both systems seem perfectly content to pay for the care they get, whether they do so out of pocket (like me) or through income taxes and health insurance premiums (like the majority). A big reason for that is quality: generally, people are willing to pay when they perceive they are getting value for their money. At the same time, in both systems as I’ve experienced them, the actual business of payment is kept physically separate from the provision of care.

I’m arguing that this segregation of business and care in medical services is not incidental to the subjective experience of quality and value on the part of the patient. Not having to deal with the “show me the money” issues up front, when you come to a doctor’s office or an ER in pain, makes a huge positive difference from a patient’s perspective. I hope that more Americans will get to test my claims for themselves, on home soil, rather than having to come to Europe to experience the enormous difference that such a simple change can make.

This is a reply to Chris, in case the WordPress system doesn’t format the comments to make that clear:

You may have noticed that I put “socialized medicine” in quotation marks in all instances (two) that I used the term. It’s common to do the same with any term a writer finds dubious, or unworthy of being taken seriously. It’s a signal to you, the reader, to treat the term in quotation marks as absurd, even laughable. That’s what I wanted to convey about the term “socialized medicine:” whatever empirical meaning it may ever have had, in the US context it’s now just code for Something Different and Scary. It’s a political confection designed to elicit an emotional response, rather than conveying information, much like “death tax”–which is always (outside of so-far-right-we’ve-fallen-off-the-flat-earth circles) shown in quotation marks.

You know how some comedians make air quotes with his fingers around certain terms around during their routines? They are using this “quotation-marks-mean-this-is-absurd” convention, adapted for oral presentation. So when I wrote “socialized medicine,” that was a way of signaling that I find the term absurd and that readers should, too; which is also why I never bothered to define the term, or discuss the extent to which the systems in the UK, France or Germany might fit the definition.

Anyway, the bottom line is: don’t worry, I never thought France had “socialized medicine.”

Brooke and Jay, maybe you remember that Krugman was a keynote speaker at the ASA, what, three years ago (in SF again, IIRC) on a panel chaired by Juliet Schor with co-panelist Fernando Cardoso. He made pretty much the exact same points he makes to day in that blog post.

BTW… that year, Michael Burawoy was President and the line-up of speakers was quite amazing: Mary Robinson, Arundhati Roy, Alain Touraine (not a big fan of his latest work, but still), Johann Galtung, etc.

From the perspective of a European who had to deal with the US healthcare system recently, I agree that the separation of the health and business aspects that generally prevails in Europe is much better.

Our 18-month old son came down with chicken pox on a recent visit to Boston, and even though we had full health and travel insurance with a major insurer, we still had to pony up at the hospital for some doctor to look at him and say ‘yup, that’s chicken pox’, just because they couldn’t find a US address for the insurer!

We gave them my brother’s address (a US citizen) after which the hospital credit control dept harassed him for a good few months over some $50 additional charge the had invented.

God forbid they would call the damn insurance company or use their imagination or anything !

I’ve been getting great treatment from the VA hospital, though I doubt that turning the US health care system into a single-payer system would make the same level of care available to everyone. Still, its been such a wonderful experience seeing doctors and nurses that are only interested in treating me, being very thorough and not rushed in their work, and although they do avoid expensive medications and treatment when something more conventional will do, the overall level of care and treatment has been so impressive. I’m losing my VA hospital eligibility soon, and have nothing to replace it, I’m a little worried.

I’m so sorry to hear about this ordeal. The post-exam harassment (for $50!) is particularly egregious, but unfortunately not unusual. I hope your son recovered and didn’t have any problems flying home. My first thought when I read your story was to wonder if the hospital or the airline made some attempt to quarantine your son, given the pandemic fears of late (even though chicken pox is no swine flu, people are scared and will freak out at anything).

I’m glad to know that VA is providing good-quality treatment; after the scandal broke last year about the poor conditions at Walter Reed, the veterans’ health care system seemed to be in bad shape. Perhaps the problems are more localized than systemic?

I totally agree that the concepts of care and payment are antagonistic, and US MD’s used to separate the two, but the no show rate of appointments and the resulting overscheduling and delays has made the continuation of this impossible. I am a physician and both my parents are physicians and the combination of payment and care is distasteful to all of us, however the persistent abuse or neglect of patients to keep there side of the deal makes it impossible for a small business owner (which is what most private MDs are, whether they like it or not) to survive when they provide care without payment. Doctors use their appointment schedules to predict income and provide salaries and benefits (most expensive of which is health care While the occasional no show is understandable for unforseeable circumstances a no show rate of 50% or so is unsustainable. So, doctors overbook. I am digressing- part of the problem is the concept that people don’t seem to value what is free here in the US. Paying the copay at the time of service causes the patient to be invested in the care that is given. MDs really can only instruct the patient and the actual tasks are usually up to the patient (taking medicine, losing weight, quitting smoking- these are gross over simplifications considering all the cultural and societal facets). I totally agree that requiring the patient to pay in full or the bulk or the treatment costs at the time of treatment is ridiculous and untenable, however when the insurance companies continue to decrease reimbursements the balance has to be made up somewhere. I don’t understand why everyone is rushing to protect private insurance when their entire business is to reduce medical costs- putting the squeeze on both the patient and the care provider. Our system is broken in so many ways. Really, most physicians just want to provide care and are unwilling business people. I have joined Kaiser Permanente to try and avoid the burnout, but we’ll see how that goes.
I am interested in everyone else’s viewpoints on this subject.

But as someone who helps my elderly parents deal with their insurance bills, I can’t begin to count the number of instances when they were hounded (for there is no better term for it — involving collection agencies, etc.) for, say, owing a $4.00 in some fee or other.

My parents are extremely hard-working, conscientious and decent people who’d rather die than suffer the indignity of not paying their dues. If they happen to owe something, they do so by an omission and/or (too often) an insurance error.

No matter. The blood-sucking vampires (i.e., insurance companies — I’m not being too harsh, am I?) will pursue them and anyone who owes them anything, no matter how small and/or ridiculous the charge, till the end of times (or your death, whichever comes first; but then, the burden shifts on your survivors).

There is no limit to the American health “care” system horror stories. It’s plainly unconscionable that there is even a debate about the necessity of changing it.

In my small village in France, the doctors handle everything: care, billing, etc. You go in, wait, see the doc, he takes your insurance card (if you are French) or you 22€ payment (if you are not) and then hands you a reimbursement form if you want it. No secretaries, no assistants, no overhead. Works ok for us. In NYC the situation is the opposite: several layers of assistants, the doc doesn’t do anything apparent with billing, and it’s often a convoluted process to get reimbursed even when you have insurance! I much prefer it here, even if I have had some out of pocket expenses (totaling about $400 in over a year, due to an emergency; it would have cost me far more in the US, where I also pay $6000 per year for the luxury of insuring my family).
Quite a contrast!

To JHS:
WORD.
Also: house calls. French doctors make them. So does my German GP. It’s f-ing miraculous. I think most US docs (except perhaps in very remote rural practices, where people don’t have any transportation–public or private–to get to doctor’s appointments) stopped doing that around the time of William Carlos Williams (physician and poet).

I live in the UK but my dad’s american and my mum lived and worked there, very poor, in the 60s. My mum worked in a Kaiser hospital in the 1960’s in California, and once patients’ healthcare ran out, they just got them carted off, god knows where by god knows whom, including a whole small family from a car crash – they didn’t ask who was taking them away, an ambulance came one day and they shoved them in it…She has loads of horror stories, some so bad she won’t talk about them.
UK socialist party Labour invited Kaiser, with a couple of other US hospital brands, to advise them on cost savings a couple of years back. Kaiser are one of the best providers I heard.
Very rich housemate from america (student) got loads of healthcare done here for free to save money; friend’s housemate from Czech Republic was sent back there (by coach, 3 days, in pain) for emergency cancer treatment, died there 2 weeks later. Don’t know how they vet this ‘health tourism’.
Italy (I worked in psychiatric unit there 1999) although they have little/no ‘pension’ for people with mental health or learning difficulties, and the doctor gets a kickback from the lab for every test you take, so my mate with asthma was made to pay for a blood sugar test and others every time she wanted a new prescription for medication, but they have a simple system of ‘free’ and not free drugs – i think it was named after the colour of the prescription slip and might have involved 3 levels. Anyway, some are free (lithium salts, insulin) others aren’t, and maybe some are a bit subsidised – all I remember is everyone ended up on lithium therefore.
Germany last autumn,I was working in a hotel there, in the news: the private health insurers held the government to ransome for extra money, claiming they were going bust and everyone’s healthcare would disappear: natch, Merkel had to pay out.
We have one emergency number, 999, for police/ambulance/fire, as logically they’re all state provided. I hit my head 2 years ago in Holland and passed out for 3 hours, came to briefly yelled friend called an ambulance. Ambulance wanted 200 euros up front or a private insurance number – didn’t understand about the nhs. Didn’t check me for concussion (at this point nobody realised that i had passed out when i fell over because i couldn’t communicate much – remember, by this time Natasha Richardson had died of a blow to the head) said i didn’t need stitches and left. I’ve called numerous ambulances in uk as a careworker and the FIRST thing they do is check for concussion, they’re really careful.
In Italy one man in our unit had a heart attack. They rang round all the ambulances (fire service, police, various catholic charities) finally got one but it got lost, took nearly 2 hours to come and take him to hospital. Golden hour, hahaha. Sardinia now has a national ambulance service you can access using the emergency number, rather than getting a phone directory and ringing round. Noticed Germany still doesn’t though.
Before I went abroad i believed all the ‘nhs is terrible’ stuff. But don’t worry, our ‘socicalist’ government is already privatising it, they already have the delivery service, or like their commissioning of the computer system, where they refused to commission to the standards the nhs said were necessary and went for a cheaper siemens: now, its failure proves the nhs is incompetent…Next year the rightwingers will get elected (a dead cert) and finish it off.

My experiance with Canadian health care is the exact same as the French system described above. I show up to the Doctor’s office, show them my health insurance card, they see me and I don’t need to pay anything. If you don’t have a card you pay $30 and get a reimbursement form.
– Also people I have known that needed care for life threatning issues i.e. Cancer have recieved prompt treatment.